Ann St of Shady Brook II

The facility failed to ensure that the evacuation capabilities of two residents, including one with cognitive impairment and one requiring physical assistance, were in accordance with the evacuation capability listed on the facility's license. During a fire drill, staff directed family members to evacuate a resident with cognitive impairment rather than providing the necessary assistance required by the facility's licensed capacity.

During a fire drill on 09/02/25, the Health and Wellness Director instructed visiting family members to evacuate Resident #1 from the facility rather than assisting the resident themselves. The resident, who has diagnoses including psychosis and hallucinations, was observed yelling and moaning in bed, requiring verbal prompting from staff due to high anxiety and confusion.